Episode 23 - Heatwaves, CQC and GP reimbursement

[Music] Welcome everyone to the RGPM podcast, Ten Hats. I'm Ali and today I'm joined by my colleagues, Robin, Kay, Kerry and Ed. Wow, it's been. what a score to this week. How's it been for you in practice? It's not been fun. I think there's a lot of us who just stay is. My building is quite moderate but we don't have air cord in every room. So we've had to adapt, let's say. There's been lots of ice lollies. Everyone loves the ice lolly. Robin, you said air con in every room. We haven't got air con in any room. So I've been coming in extra early and opening the windows. Now, one of the things I've noticed when I've opened the windows is that we're in an NHH. You know, an NHS, ordinary NHS building. The windows won't stay open. So in a variety of different rooms, we have different solutions to opening the windows. So different things pop in the windows open. I know my partners are going to listen to this podcast because they do every month. I don't know if they'll thank me for saying that there are some urine pops and some space of devices. And even a whole punch holding one open. So on my list of things to do next week is to sort out the damn window. It's been one of those weeks where you forget that you're pleased that we don't live in 30 plus degrees climates. I love the heat. But not when I have to work. It's all the while having that temperature when you're on holiday. But it's pretty hard when you're working in a non air conditioned building. So yeah, I'm not unhappy that the temperature has dropped today. I'm saying it's sort of feeling quite smug in my air conditioned office. So that you end. Obviously I love coming to work, you know, but I must have enjoyed it a bit more than I asked for you days. Leaving my poor suffering wife at home working from a very, very hot house coming into work and turning on the aircon. But I won't talk about too much because I'm just so getting gagged looks for your last. I was really good to you. I've certainly enjoyed the drive home for an hour and air conditioned. Hey, the petrol pumps have as well. I've used so much more fuel with the aircon on. So I've got electric car and it's much more efficient. Oh, really? It's more efficient in the heat. So I just wanted to take a little bit of time to reflect on practice manager wellbeing today. I mean, it resonates with with all of us, I think. And at the recent IGPM Southern Conference carried it a really well received talk on looking after yourself as a practice manager. And also we've just launched our IGPM safehouse service, which I think I suppose unfortunately has already been used in the. In the weeks after launch. How do you guys feel about this? I guess I can start. I did deliver that session at the conference in Southampton and. It's something I feel really strongly about. We're. As practice managers, we are always looking out for the health and wellbeing of our teams. And we are often the ones who we neglect and we think of last. And we always we are always thinking how can we develop our teams and how can we make sure that our teams have a manageable workload and. And often. The practice manager is lonely is a lone voice in their practice and you may have somebody who doesn't have any support from their colleagues or their. Their team to say, well, what about you? I'm very lucky in that respect in the place I work, but. As practice managers, we're very bad at thinking about our own wellbeing or not recognizing when it's time to say enough is enough. I think as well, one of the things that. I was res has resonated with me this week. I was doing some de escalation training for a reception staff. And one of the things I talk about in that session is about moral distress. And I think there's a lot of focus on moral distress for clinical staff, you know, when when they feel like this is something I'd want to do for this patient, but I'm not able to for whatever reason. I just feel that a lot as well. Sometimes for patients, you know, when we're super busy and patients want to complain because they can't get an appointment. And we're trying to say to them, look, I know you need an appointment, but I just don't have one to give you. But also it's holding it for staff as well. So in my surgery, we've had. But to staff off at the moment is they've had some briefments, which is really horrible. Obviously, we're all thinking of them, but it's then I'm trying to make sure that I've covered that that they wrote the work that's coming in making sure that we're okay covering some of it myself. And I'm which I'm happy to do because they're my team and I really want to live after them. But when you've had a really busy week, especially when you've been absolutely melting like we have this week, there comes a point where I was sort of thinking to myself the day, he's actually looking after me. And I'm really lucky. I've got amazing partners who do check in on me. And if I didn't have that, though, I think I would really, really struggle. And I think that's a common thing that we hear amongst our members all the time. And so we were really, really key to do something about that and offer a service where people can just come and get that support. I wonder if you'd just let me read some feedback from one of our members who actually, she's really happy, she's really happy that we share this publicly. So I'm just going to read out what she said to us. Obviously anonymise it. She said. I wanted to give you a reminder of how amazing you all are and the influence you have had on me and other managers. I'm going to be honest with you. Last week I had a really bad week felt very overwhelmed with my workload. Had staff sickness deadline, meaning I had to work till midnight to get work done. And unfortunately on Friday, I had a medical episode that ended with me being admitted to A&E. I'm okay now, but they have said this is the result of stress and my body just saying enough is enough. And what a wake up call that was. I'm only a year into practice management and I love it, but honestly just wanted to call it a day. I reached out to the IGPM safehouse and I got allocated the lovely, and I won't say this person's name, but safe to say it's one of our great reps. Who was all I needed to get me back, believing in myself and just with a safe person to talk to. She has been so supportive and have helped me with some ideas to support myself as a PM. So a week on, I'm sitting back at my desk knowing I can do this. So please just send my thanks to the whole team because what you all do is amazing. And this has had a huge positive impact on me as a manager. So you know what, take take about everybody, you know, and to that one manager that actually put a plea on one of the groups that she was having such a bad day, nowhere to turn. That has made this happen and the ripple effect is just huge. We used to say, isn't it, what we still do, that being a practice manager is a really lonely job, because quite often you're the only one who's doing it in your practice. And who do you go to for support? And so this is it, this is where it is. You know, there's a whole team of us that we can allocate you. So I want to speak to you, have a have a chance to spit ball through your ideas, talk, you know, offer you any advice and support that we can. So just a listening year, a lot of the time, because a problem shared literally is a problem. How does it and I think we're really, really proud to have this service because I think it is very much in need. That's one of the amazing things about being an IGPM member is the support that we provide for our members. I think something that the members talk about a lot and certainly at the primary care show. Lots of people came and said how much they they really rely on the WhatsApp groups. And they're just so incredibly popular with with the members. Yeah, definitely. And you know, when when we were talking at that show about people say, well, what do I get when I join when I sort of showed them the different groups in that WhatsApp community. They're really astonished. And I keep saying, you know, you know, pop a question in any of these groups and you'll get an answer from, you know, multiple people within minutes really because it also just for me shows what an amazing community of people practice managers are. That they're so willing to just offer support and advice and share ideas and you know, not keep things to themselves like we see. Like people put in there all the time. Well, you know, I've done this amazing thing and they haven't gone, but you it's mine. You can't copy it. It's like we try it itself. See if it works for you because that's you know, that's how we survive as well. Isn't it? It's making sure that we're supporting each other. And what better way to do that than just literally through through your phone that you're probably using all the time anyway. So get some help. So you know, get some expert help. Boy, you're there. I think it's it's one of those things where I mean, certainly, you know, we're all we're all members as well and I will often ask a question and you get, you know, it's almost instant gratification. Somebody replying give you support or their advice. And it's one of the things when I'm talking to people about why you should be a member that sounds really quite a small thing or we've got some WhatsApp groups, but actually the power of those groups and the different people you can tap into is incredible. And I don't think we should underestimate that. I think you put a question on there yesterday, Kerry about looking for a large practice using a particular bit of software and got responses straight away. Yeah, absolutely. There also massively help for when you're going through challenging experiences. I mean, Ed, I think you know, just been through your CQC? Do you want to share a bit more about that? Yeah, I think it's linked to safe house as well and the pressure these inspections put on practice managers. Practices will be aware that in March CQC changed the way they're inspecting some practices. Those practices who have already received a good or outstanding rating between 2017 and 2022 will get a new type of inspection which is a more focused inspection looking at the 10, looking at 10 domains instead of the usual 30. So I guess the good news about that, which is all about the good I think first is that that is a watered down inspection so it should be an easier day not so stressful, hopefully not having to pick so many documents together. And hopefully be able to get through that. It means that CQC deem your practices low risk because you're already good in outstanding so that coming in just to make sure that everything is still okay. However, I think sort of for us as profession some of the anxiety we have over it is that this new inspection is a non-clinical inspection. And actually my experience was the only person they required to be there for the inspection was the practice manager and that is the same we've seen in other parts of the country as well. And that is a huge amount of responsibility because effectively the CQC are sort of taking the view that the rating and the safety and the quality of a practice can be delegated to the practice manager and the practice manager has a responsibility for that oversight. And you know that is a lot of pressure. They have also reduced the timeframe from two weeks notice to five days. So when you get one of these inspections, yes they're not looking at so much they're looking at just the 10 out of the 30. But you've got only five days notice and essentially it's a practice manager inspection. Or it could be viewed as a practice manager inspection. Yeah so I went through a few weeks ago. The inspection was positive and I must say that the inspectors who came in were looking for good and so I won't criticise our inspection team. But again about perception the three inspectors who came in and sat with us none of them had worked in primary care before. And there's an argument to say you do not need to work in primary care to be a good inspector. But of course there is the perception that if you've not done our job can you really know what it entails or what good or I'm just going to do you want to come in K on that? I was just going to say I asked that specific question of CQC last week the conference we were at. And their view was that there wasn't enough special inspectors with general practice management experience. So what they did in their sort of pre inspection searches was see if they thought there would be needed to be a deeper dive into practice management. And if there was then they bring that special inspector in or that special investigation in. So I guess when there isn't one that means they're not worried about you as a practice manager. But it'd be nice to hear that rather than just they're not be one there and have to explain acronyms and you know all the rest of it which actually took me a long time when I was inspected. So I'm just going to interrupt. No no so yeah it's I agree K I think being more open about it would be really helpful. Professor Boiler Awalabi who is the new chief inspector of primary care she's a GP she's almost been the role for a year now. I think all of our experience is that she gets it and you know she's trying to turn around a ship. CQC itself is pumped for a really rough time continuous change of leaderships you know potentially not well-led the culture has been tricky and I do think that they are trying to turn some of that around. But you know I was one of my you know another things which disappointed me is this is a non-clinical inspection but our inspection team had not heard about the IGPM which is which is a shame because the leadership of CQC know about IGPM very well and actually we're working with them. We're on various steering groups with them to try and you know give our opinion and try and collaborate with them to try and make inspections fair. Through our WhatsApp groups and our CQC chat the other thing which is worrying for us is that these new inspections are still quite variable depending on who you get on the day. We've had some practice managers saying that they've had sort of over a hundred documents requested ahead of inspection with just five days notice. We've had others who've said that they've last the all day long and then others have said that you know it was very light touch they came in for two hours and they left and happy days. So there's still quite a lot of this to go through. They've only started this in March and you know we've heard that they're sort of trying to learn as they go and again does that feel fair and transparent for those who have the inspection early versus who gets it late. So that's you know I was exhausted from the light touch inspection I really was so it didn't feel too light touch for me and there's a couple of other things you're unlikely to have your rating changed from from the inspection. So unless they find something which they're really concerned about and then they might come back in and do a full inspection which made drop your rating then you're likely to stay the same rating as you are which again does that mean you're not incentivized to try and really demonstrate excellence to try and for those practices who are trying to get into outstanding. The the chair of the ICGP brought up a steering group me and K were just on this week with CQC that if you want to go for outstanding you need to be able to demonstrate more than what they can do in these light touch inspections and then we'd have to invite them back in for a full inspection. Now I know that I I I would even if you know obviously it's very nice to be outstanding but I would not want to invite CQC back for a full inspection just after having a light one. So I do think that's a missed opportunity for CQC to be able to all for practices to be able to show CQC that they are particularly proud in some areas. Ed can I just add there as well that actually it's poor for all of us because we then can't see what good practices going on. So if you know all of us read other people's inspections all of us look at what is brilliant out there and actually we want a copy we want to do it we want to do all those things we want to learn and if we're not sharing it then we're never going to get better as a system. I completely agree and so they're doing this light touch and this partly because you know and both have experienced this well they are really behind on inspections that the pandemic paid them really far behind so this light touch essentially using people who haven't got huge expertise in primary care using their fuller inspection team to try and catch up on inspections but beyond that CQC are also relooking at their frameworks and they've got some new draft frameworks out which the IGPM have been invited to read them review them and work in a larger steering group with them so that we can give our views and whether these frameworks are fit for primary care and a couple of us were just on the call yesterday I think it was yesterday this week with them and and you know I feel that they are trying to collaborate and work with us to get a fair inspection process going forward which is also consistent and to be you know they do have a hard job because at the end of the day human inspectors will have their own bias and views and trying to make everyone consistent across the country when practices are all quite variable is quite tricky. I would say that the the pressure on a practice manager or Juni's inspections I know that K has been through it recently, Keri has been through it quite recently it is enormous and you know and it's we have to take ownership over something so large and failure you know or poor CQC outcome can be extremely upsetting we know that the the story is about off-stead and the pressure on head teachers and there's loads of parallels which can be given to us as practice managers and I know that there's lots of concern about that we still use the one word rating. I think the thing that worries me and it links back to what we were talking about in terms of safehouse is how isolated some practice managers are. Yeah. And With this emphasis on a management led inspection, there is a danger for some practices who don't have support from their partners or from other colleagues in the practice that it is all on them. And I feel fairly sure that if we ended up with a light touch inspection so-called, then I would still have support from the team I work with. But that's definitely not the case, you know, across the country. And we know that from the comments we see about practice managers who are struggling. I have to say, actually, the WhatsApp groups and practice manager colleagues up and down the country were so helpful when I told them that I had this inspection coming. And they said, "What do you need? Is there anything you do?" And I was sort of 50 or 60 documents from various people. You know, maybe feel that wasn't alone. And actually some of that stuff was really helpful and got me in the right frame of mind for the day. Again, just showing the power of our community. And the fact that we just want to help each other out because we know how stressful these are. And again, if you are an IGPM member, you can access those WhatsApp groups. It's in your welcome email when you join us. If you need, if you want to join and you're not a member already, just pop over to our website. Robin, do you want to give us a bit of an update on what's happening with the GP reimbursement scheme? Oh, this ruddy scheme. (laughs) I feel like I've done nothing but talk about it since it came out. Yeah, so I also did a recent interview with GP online about this as well. And since then, the roading around it has changed. So initially, when this scheme came out, so this replaced the PCN capacity and access improvement payments or caps as they record, it's now going to go directly to practices, which initially sounds like a yay, but the contingency of it is that it must be used to recruit or give additional sessions to salaried GPs with the aim of improving access by increasing clinical capacity. We've pointed out multiple times, well, the concerns we have around this, if you just want to increase GP appointments, why is it only a salaried, a local partner, these are all GPs, they still see patients, but that's got to be for salaried GPs. And I'm assuming it's to try and tackle the apparent under-employment and unemployment of GPs at the BMA if it's talking about for a long time, fair enough. But the government are baselining you from the first of April. So these people need to be either new salaried GPs on new contracts. They need to be existing salaried GPs doing additional sessions and they will be checking your NWRS to see what those sessions were pre-first of April. Or they have, and I said that if you were previously funding a GP, a salaried GP, from CAC funding via your PCN, they can remain on this fund and you can claim to them. But you will need to notify your ICB that that's what you're doing and you may need to provide evidence that they were funded through CAC before. So bear all that in mind. The other big issue is that they talked about this funding initially being non-recurrent as in they couldn't commit to it going past the 31st of March, 2027. And that in itself raises a whole load of HR issues. So if you are bringing on a new salaried GP on a fixed term contract and that funding is going to end, that creates a redundancy situation because that post no longer exists. If you are using a BMA model contract for that salaried GP, you should be recognising their continuous service from the point essentially where they've started GP training if they've never had a break. And that means that as employers, partners could be taking somebody on to do nine months worth of work, making that person redundant and paying the might 10 years worth of redundancy pay, which is a big issue. So we've highlighted this to the government. And we've also been highlighting it in our network locally and through our members group to say just be mindful what terms you're offering to those salaried GP's if you are going to use this money to recruit someone. The safest option was potentially taking a low-comon and putting them on a PAY contract because low-coms you haven't worked in a practice or under an NHS contract for three months where they are employed have broken their continuous service. We now have been told and the SFE was then published with the indication that this funding will recur. But do you trust that? It's my question. You know, this is funding that previously has been coming through one route and has now been changed. Is that funding going to stay exactly as it is? Is it going to continue? We're also still waiting for a longer term contract, aren't we? And so we don't know and we've been promised a new and new contract offer before the end of this current parliament. Time is ticking. I'm just not that confident in it. So I would just say to people, air on the side of caution, we don't want to be encouraging people to take salaried GP's on and not use BMA model terms. But the terms just have to be no less favorable. And you can't really put your practice finances at risk. So it's worth having a discussion with someone if you're offering a job to say, look, there's a reason why I'm not able to recognise your continuous service. But I can offer you so and so instead. And it might be a nice sort of kind of compromise that you can get to. But Jesse, I'd be careful that you don't fall into that redundancy track. I know a lot of practice managers have said, oh, but you know, it's only like less than two years. So redundancy won't be applicable. It will be if you recognise that continuous service. And that's really, really important. Yeah, I think, you know, we're really lucky to have you robbing with your HR expertise. But this whole change again is, is again, a new pressure on the practice manager, having to be an expert with one of their 10 hats this time, their HR hat to make sure that we do this recruitment safely. There's a lot of pressure from us from our clinical team, saying, wait a minute, this money started in April. I mean, to be out there hiring these doctors, you know, you lose it. And we're like, okay, we're just going, but we haven't seen sort of the guidance. We don't really understand what's going on, which want to make sure we do this safely. And then there's going to be, you know, all of these things generally come down to more workload for us. When we do want to do this, we've got to go through this C-CRS local portal. We've got to upload, upload contracts of employment. And then we've got to upload a pace it. They're pace it every month because we're all lying, you know, because they can't be trusted. So we have to go through this whole sort of administration burden to prove that these GP hours are additional. And, you know, I don't think any of that's ever taken to account when these, when these schemes are come up with. No, and I think as well that the concern is that we raised during the consultation phase was around this, this funding's being used by PCNs for other things. You've just taken it. So there, you know, there are people who were using it to fund other staff that weren't GPs, but who were providing services that were freeing up GPs to see more patients, you know, home visiting services staff by paramedics, prescription hubs staff by pharmacists. They've now either had to shut that service down, but find that funding from somewhere else. And it's just constantly putting more pressure on practices financially to kind of stay afloat. And then when you couple that with the increased demand that we've had also since the first of April around online systems, and then we've had a group of people who are doing it, and we've had a group of people doing it, and we've had a group of people doing it, and we've had a group of people doing it, and by worry here is we've created the conditions for a bun fight, for salary doctors, and we know that yes, there may be some who can't get employment now, but there's going to be winners and losers here, there's going to be practices who've got these funds, and just will not be able to find a GP locally to employ them. And practically, what have the three of you done? And I can tell you what I've done, which is nothing yet, because I can't plan on sort of hanging fire and perhaps doing something for six months later in the year, that will also help me with winter pressures. I know it's boiling hot, and I shouldn't be thinking about winter, but hey, how? So we did, we employed a salary GP back in, I think it was 2024, over and above what was our normal staffing level at that time, which we did use some of the cat funding towards after we'd implemented our online total triad. So we've got those systems embedded, and we've changed our to left in everything, and then like, actually, we just need more staff. So we have approached our ICB to say, I want to claim for this person, because that's how I've been paying for them this whole time. But we have to await the ICB approval to that as well to make sure it goes through. I think my biggest concern, like Edda said, is if practices don't get on it in time, or they don't use it, the funding just goes back to Treasury as well. It's not even ring fence of primary care. And that's a bit of the concerns, that was a core bit of our finances from PCNs, that was helping prop services out, which is gone. And it's not an insignificant amount. It's on average for a practice, it's just like £40,000, £50,000 a year, which is really significant. So just think carefully about your terms. If you're planning to recruit to it, how are you going to evidence what it is that you're doing, and just please don't end up with a massive redundancy liability at the end of it. And Kerry, what about you with your kind of PCN sized? Practice? Well, I mean, since there's been some clarification on being able to use roles, which we may previously have recruited to under the PCN, are using cash. funding. Actually, we are probably going to be okay because we'll advise the ICB that we're moving those members of staff over. I mean, it doesn't give us long-term stability if suddenly they saw the funding ends next year because we've employed those members of staff. But, yeah, I mean, from a purely selfish point of view, there's probably not a lot for us to do other than just to make sure that the ICB knows who we're transferring over. So, yeah. I think to be fair to our commissioner colleagues, they also have not had clear guidance yet about what they can allow and can't allow. So, I think, like, it sounds like all of us, we've been left in limbo not knowing whether people have employed previously. They'll interpret as being, yes, that was sort of you use cap funding to employ them and how straight they are going to be about that and timelines and whether local interpretation is going to be, it's going to be different. So, what they do up in Manchester might be different to what they do in Hampshire in terms of how they interpret what, you know. So, I think it's a big mess and actually we're all losing out right now because of it. Thanks. That's a really interesting. Yeah. Very true. Anyway, we want to enter on a negative alley. Give us something out. It's about five months. We're going to do something to be happy about. We are and I just wanted to flag really and say, you know, please consider what you can do to demonstrate the practices, acknowledgement or support for LGBT patients and staff. And perhaps I can finish or share a story with you about something that happens to in our practice about 18 months ago. So, one of our GPs who is an older GP and I think you wouldn't necessarily consider him to be, you might consider him to be somewhat old fashioned in how he looks. He's a lovely, lovely GP but from a purely visual point of view that you might not anticipate that he would be the most open-minded in terms of how he would deal with somebody. And in our practice, we encourage all of our teams to either wear pride land yards or we've got some pride pin badges. And he told me a story about a patient he saw about something completely unrelated and he was wearing his land yard. And a few weeks later that patient went back to him and asked specifically to speak to him to talk to him about their gender identity. And explained to him that the reason they felt comfortable to do that with him was because he was wearing the pride land yard last time he saw them. And it just struck me that it feels like a really small thing that we do to put up a poster in our reception area to say this is a safe space. If you've got, you know, the the ongoing conversation about access to public toilets for trans people, if you're able to, to actually say yes, please use these toilets because they're unisex. They're really small things but they can have a really big impact on individuals. So I guess a bit of a plea really is think about what small things you might be able to do during Pride Month. Remember that you may have members of staff who work for you, who you're not aware of a member of that community and may feel supported by something small that you do. We'll be doing some messages to our members through the Pride and Practice WhatsApp group with some ideas that they could, their practices can do small and large throughout the month but take time, celebrate the month and have fun. Amazing, thanks, Kerry. And that group is one of the great conversation stars, isn't it? And people share stuff all the time. You also did an induction pack that's a member's own resource, didn't you? We did. Yes. So there's a short PowerPoint slides that you can use. Either as a presentation to your team to help people understand some of the terminology and some of the, the sort of pitfalls and the things they can do to show support. And you can use that for a team training session and it comes with full sort of speakers notes if you like for those who may not feel as comfortable talking about it. And or you can use it as an induction pack for all of your new new stuff. Well, thank you. That's a much happier topic to end up. Thank you all for taking time out this morning to share your experiences and your insights into everything across practice management. And looking forward to talking again next month. Thank you, Kerry, everyone. Thanks everyone. Bye. Bye.